chest wall injuries, rib injuries

Chest Wall Injuries

Chest pain is a common complaint in athletes and has a number of possible underlying causes. It may be related to the structures of the anterior chest wall; those contained within the chest such as the heart and lungs; or referred from the neck, shoulders or back. This article focuses on those conditions arising from injuries to the chest wall, although clinicians should consider other possible causes when assessing an athlete with chest pain.

Anatomy of the chest wall

The chest wall is composed of 12 ribs and the two layers of intercostal muscles that lie between them. Beneath each rib lies a neurovascular bundle, containing an intercostal nerve, artery and vein. It is via these nerves that pain from the neck is sometimes referred to the chest wall.

The ribs articulate at the front of the body with the sternum (breastbone) via costochondral cartilages. The sternum articulates with the clavicles (collar bones) via synovial joints.

The back of the chest wall is in continuity with the spine, and at the sides with the shoulders and arms. Thus an athlete may injure the chest wall either indirectly, as a result of forces transmitted through the chest, or because of direct trauma to the chest. In any case of chest injury it is important to rule out the possibility of an associated injury to the intrathoracic organs.

Causes of chest pain in athletes

The possible causes of chest pain in athletes can be divided into those arising from the ribs, the sternum and the joints (1).

The ribs

Stress fractures
Stress fracture is most likely to occur in the first rib. Overhead athletes such as basketball or tennis players are typically at risk here: repeated contraction of the anterior scalene (deep neck) muscle exerts bending stresses on the subclavian sulcus, a small recess in the rib bone and the most common site of fracture.

The athlete will feel pain around the shoulder or front of the neck, and possibly tenderness at the top of the shoulder blade in the root of the neck. Diagnosis is usually confirmed by bone scan, CT or MRI.

A stress fracture of the first rib needs the arm on that side to be immobilised in a sling. A soft neck collar may be useful in dealing with painful contraction of the anterior scalene. Pain usually resolves in two to eight weeks, with a return to sport permitted between four and eight weeks after injury.

Stress fractures to the other ribs are less common, but seen, for instance, in golfers and rowers. The serratus anterior muscle inserts on the outside end of the first to ninth ribs, interweaving with external obliques. When these muscles contract together they produce a bending stress at the far outside corner of the ribs – and this is the likely site for stress fracture.

In such cases, pain is often felt in the back, with tenderness over the affected rib. Plain X-rays may be sufficient to make the diagnosis, which will result in the athlete ceasing the provocative activity for four to six weeks. The return to activity should be graduated, resuming normal training intensity at eight to 10 weeks post-diagnosis.

Acute rib fractures
These are the result of direct injury. Fractures of the first and second ribs suggest a very significant transfer of energy and can be associated with underlying injuries to the thoracic aorta, brachial plexus or subclavian vein.

The patient complains of a sharp pain in the chest, aggravated by deep breathing or coughing, or by compression of the chest wall (eg from lying prone). Fractures are easily overlooked on a chest X-ray. In most cases treatment is only needed for pain; an injection of local anaesthetic will bring about immediate relief. Breathing exercises are then encouraged, alongside complete cessation of the provocative activity for four to six weeks and a gradual return to normal training loads at 8 to 10 weeks.

Support professionals should be constantly alert to the possibility of serious complications where isolated rib fractures are suspected. While the bone injury may appear trivial, underlying injuries can include haemothorax (bleeding into the chest wall cavity), pneumothorax (air leaking into the chest cavity), tension pneumothorax (collapsed lung), pulmonary contusion and visceral injury (where a sharp rib spike damages the liver or spleen).

Slipping rib syndrome
This is pain in the lower chest or abdomen together with a tender spot at the bottom of the ribcage, and reproduction of symptoms by pressing that spot (2). It is thought to arise when the cartilaginous inner ends of the ‘false ribs’ (eighth to tenth) are hypermobile – not securely attached to the sternum or surrounding ribs. The rib rides up and exerts pressure on the neurovascular bundle above. This loss of stability may be the result of a previous injury or reflect a congenital defect.

The patient complains of a sharp stabbing pain in the upper abdomen or rib cage, which lasts several minutes before giving way to a duller ache which may last several days. It may be possible to reproduce the client’s pain by pressing several points over the lower ribs. Heinz and Zavala describe a ‘hooking’ test, where the patient lies on the unaffected side while the lower costal cartilages are grasped and pulled forward. This reproduces the pain and causes a click.

Management of this condition is primarily rest, avoiding the precipitating movement for four to six weeks. The therapist should prioritise flexibility training and core stability work. Corticosteroid injection may be needed in recalcitrant cases; in severe cases, surgery will remove the anterior portion of the rib.

The costal cartilages

Fracture of the front section of the ribs (the costal cartilage) is a rare cause of chest pain in athletes, caused by sudden forceful contraction of the external oblique muscles, which may lead to an audible clicking. Tenderness is localised over the costal margin and diagnosis is confirmed by CT. In recalcitrant cases surgery may be needed (1).

The sternum

Sternal fractures
Fractures of the breastbone tend to be the result of direct high-energy trauma. The vast majority result from road traffic accidents, with the steering wheel striking the sternum, but a small number may arise from direct blows such as those received in rugby or wrestling. However, sternal stress fractures can result from repetitive hyperflexion of the torso, such as performing vigorous sit-ups over a long period. They remain a rarity, accounting for around 0.5% of all sternal fractures (1). Occasionally the underlying myocardium is damaged and care should be taken not to miss this in patients with significant injury.

With a stress fracture or minimally displaced traumatic fracture, the patient is treated conservatively, avoiding provocative movements for four to six weeks, followed by progressive strength work. If fragments are severely displaced, surgery under general anaesthetic will be necessary and recovery time may range from 2 to 12 months.

Sternoclavicular dislocation
This is sometimes seen without any history of trauma, but the most common tear, a minor subluxation, usually results from a fall or blow to the front of the shoulder, or a fall on to an outstretched hand. The impact forces the inner end of the clavicle on the affected side downwards and forwards, creating a clear asymmetry of the collar bones. There is local tenderness.

CT scans are generally more informative than X-ray, especially on the rare occasion when the clavicle passes behind the sternum, where it may endanger the great vessels.

With minor subluxations, the patient should avoid painful activities for two to four weeks. Resting the arm in a sling allows any associated soft tissue injury to settle. Activity can then be gently reintroduced. Some prominence of the inner end of the clavicle may persist but a pain-free result is usual. Gross displacements need surgery, after which the patient will wear a clavicular brace and a broad arm sling for four to five weeks.

Thoracic wall joints

Costochondritis
This is a common but poorly understood condition in which the cartilaginous sections of the ribs attaching to the sternum become inflamed. It presents as chest pain and may mimic cardiac pain. There is tenderness over the costochondral or chondrosternal joints. Other than causing a great deal of anxiety, this is a benign condition and reassurance and analgesia often work. Corticosteroid injection may speed recovery and allow an earlier return to competitive activity.

Tietze’s syndrome
This is similar to costochondritis, except that redness and swelling appears over the affected joints. It is thought to result from an inflammatory process and may be related to seronegative disease. Having excluded other causes of pain, treatment is similar to that described for costochondritis.

Table 1: Chest wall injuries, summary

Condition

Symptoms & signs

Investigations

Treatment

1st rib stress fracture

Shoulder and neck pain

Neck root tenderness

Bone scan

CT

MRI

Broad arm sling

Soft neck collar

Rest

Other rib stress fracture

Posterior pain

Tenderness

Chest spring pain

X-ray

Rest

Analgesia

Slipping rib syndrome

Acute pain

Activity related

Hooking test

Nerve block

Rest

Analgesia

Technique modification

Steroid injection

Surgery

Sternal stress fracture

Pain

Local tenderness

X-ray

Rest

Costochondritis

Localised pain and tenderness

Reassurance

Analgesia

Steroid injection

Tietze’s syndrome

Localised pain and tenderness

Inflammation

Reassurance

Analgesia

Steroid injection

Sam Oussedik is clinical and research fellow in orthopaedics at University College London. His primary interest is football

Reza Jenabzadeh is a research fellow in orthopaedics at University College London Hospital, and has a special interest in racket sports